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The aim of this study was to compare the treatment ouctomes of severe idiopathic scoliosis (IS) (>90 degrees) using the staged surgery with initial limited internal distraction and typical IS treated using segmental pedicle screw instrumentation. We hypothesized that staged surgical treatment of severe scoliosis would improve more HRQoL and pulmonary function (PF) as compared with posterior spinal fusion (PSF) for typical IS curves.
It was a retrospective review of a consecutive series of 60 IS, severe group (SG) vs. moderate group (MG) with min. 2 years of follow up (FU).
The mean preoperative major curve (MC) was 120° and thoracic kyphosis (TK) was 80° for the SG and 54° and 17° for the MG, respectively (p<0.001). The MC was corrected to 58° and TK to 32° for the SG; the MC to 26° and TK to 14°, for the MG, respectively (p<0.001). The mean preoperative AVT was 8.9 cm and improved to 2.8 cm at the final FU for the SG and from 6.5 cm to 2.2 cm at the final FU for the MG (p<0.001). At baseline, the FVC% & FEV1% values were significant different between the two groups (41.5% vs. 83%, p <0.001) & (41.6% vs. 77%, p <0.001). Compared the baseline for SG vs. the values at 2-year FU the FVC % values were (41.5% vs. 66.5%, p <0.001), and the baseline for MG vs. the values at 2-year FU, the FEV1 values were (77% vs. 81%, NS). At last FU, no complications were reported.
Gradual traction with complicity of multilevel Ponte's osteotomies and neuromonitoring followed by staged pedicle screws instrumentation in severe IS proved to be a safe and effective method improving spinal deformity (52% correction), PF (improved percentage of predicted forced vital capacity by 49%), and health-related quality and allows to achieve progressive curve correction with no neurologic complications associated to more aggressive one-stage surgeries.
Objectives
This presentation discusses the experience at our Centre with treating traumatic thoracolumbar fractures using percutaneous pedicle screw fixation and also looks at clinical and radiological outcomes as well as complications.
Design
This is a retrospective study reviewing all cases performed between Jan 2013 and June 2019
Introduction
The British Spinal Registry (BSR) is a web-based database commissioned by the British Association of Spine Surgeons (BASS) in the UK. It allows auditing of spinal surgery outcomes, patient's safety and overall experience. The clinical data include patient's demographics which is entered into the Registry by medical staff, as well as patient-reported outcome measures (PROM) that is submitted to the Registry by the patient themselves at different time periods post-operatively. It has the ability to register Device and Implants as well as co-ordinate multicentre research. This study is to identify both the staff and patient compliance regarding to data submissions to the BSR at St. George's Hospital NHS Trust.
Methods and Materials
Retrospective analysis of the BSR data for all spinal surgeries that was performed at SGH by the three Complex Spinal Surgery Consultants between 1st January 2017 to 31st December 2018. This study period allowed up to 12 months PROM data analysis. Staff and Patient compliance were analysed separately depend on the data they submitted.
Introduction
Thoracic wall surgery can cause severe pain and inhibition of coughing with effects. (1) Various local anaesthetic (LA) techniques have been tried successfully to mitigate the use of opioids alone. We believe this is the first time that a serratus plane block using an epidural catheter (SABER)has been studied in anterior spinal fusion (ASF) procedures. Our aim was to ascertain how it would affect ASF compared to gold standard posterior spinal fusion (PSF) surgery.
Materials and Methods
We identified 43 patients from the years 2017 to 2019. 24 had ASF and 19 had PSF. Detailed data were collected on local anaesthetic infusion (LAI) SaBER, mean pain scores(MPS), morphine, chirocaine usage and hospital length of stay (HLOS). We divided the patients into 4 groups: Short PSF (SPSF), Long PSF (LPSF), Thoracic anterior fusion (TA) and Thoracolumbar anterior fusion (TLA) surgery. 4 patients in the SPSF and 4 in the LPSF group had LAI because they had a costoplasty. All patients in the anterior group had SaBER.
Introduction
Tomita En-bloc spondylectomy (TES) of L5 is one of the most challenging spinal surgical techniques. A 42-year-old female was referred with low back pain and L5 radiculopathy with background of right shoulder excision of liposarcoma. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation and therefore was not suitable for stereotactic ablative radiotherapy (SABR) alone.
Planning Methodology
First Stage: Carbon fibre pedicle screws were planned from L2 to S2AI-Pelvis, aligned to her patient-specific rods. Custom 3D-printed navigation guides were used to overcome challenging limitations of carbon instruments. Radiofrequency ablation (RFA) of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac-tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone cutter assisted inferior L4 and superior S1 endplate osteotomies.
Second stage: We performed a vascular-assisted retroperitoneal approach to L4-S1 with protection of the great vessels. Completion of osteotomies at L4 and S1 to en-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Sacrifice of left L5 nerve root undertaken.
Thoracolumbar injury classification systems are not used or researched extensively in paediatric population yet. This systematic review aims to explore the validity and reliability of the two main thoracolumbar injury classification systems in the paediatric population (age ≤ 18). It also aims to explore the transferability of adult classification systems to paediatrics. The Thoracolumbar Injury Classification System (TLICS) published in 2005 and the AO Spine published in 2013 were assessed in this paper because they both provide guidance for the assessment of the severity of an injury and recommend management strategies. A literature search was conducted on the following databases: Medline, EMBASE, Ovid during the period November 2020 to December 2020 for studies looking at the reliability and validity of the TLICS and AO Spine classification systems in paediatric population. Data on validity (to what extent TLICS/ AO Spine recommended treatment matched the actual treatment) and reliability (inter-rater and intra-rater reliability) was extracted.
There is an “almost perfect validity” for TLICS. There is a “strong association” between the validity of TLICS and AO Spine. The intra-rater reliability is “moderate” for TLICS and “substantial” for AO Spine. The intra-rater reliability is “substantial” for TLICS and “almost perfect” for AO Spine.
The six studies show a good overall validity and reliability for the application of TLICS and AO Spine in pediatric thoracolumbar fractures. However, implication of treatment and anatomical differences of the growing spine should be explored in detail. Therefore, AO Spine can be used in absence of any other classification system for paediatrics.
A previously fit and well 58 year old male suffered from a bilateral psoas haematoma (PH) following 52 days of veno-venous extracorporeal membranous oxygenation (VV-ECMO) for severe Coronavirus disease (COVID-19), refractory to all non-invasive and medical therapies. He developed multiple complications, including inability to walk or weight-bear, due to lumbar plexopathy triggered by bilateral PH compression, compounded by COVID-19-related mononeuritis multiplex. The patient was referred to our institution with a known diagnosis of bilateral PH and after spinal multidisciplinary team (MDT) input, was deemed not for surgical or interventional radiology treatments. The patient received extensive neurorehabilitation, coordinated by multiple MDTs. Although PH has been correlated to COVID-19, to the best of our knowledge this is the first reported case of such a complex presentation resulting in a dramatic bilateral PH.
Health records from 3 large UK teaching hospitals were collected regarding treatment and follow up appointments, following patient's written informed consent. Patient's comorbidities, duration in hospital units, MDT inputs, health assessments, mobilisation progress and neurologic assessments, were all recorded. Data was collected retrospectively then prospectively due to lengthy in-patient stay. The literature review was conducted via PubMed and open access sources, selecting all the relevant studies and the ECMO guidelines.
Patient received treatment from 3 different units in 3 hospitals over 212 days including 103 days in neurorehabilitation. Involvement of physiotherapy, dietitians, speech and language teams, neurologist, neurophysiotherapists, occupational therapists was required. The patient progressed from a bed-bound coma and inability to walk, to standing with lower limb backslab at discharge. Additionally, he was referred for elective exploratory surgery of the psoas region for scar debridement and potential nerve graft repair of the lumbosacral plexus. The surgery outcome is cautiously optimistic, with some improvement in nerve conduction studies, however is currently unknown regarding recovery progress and return to premorbid functional baseline.
The novelty of this presentation yields significant learning points regarding early recognition of PH, requirements for vast MDT input and specialist use of VV-ECMO in severe COVID-19 patients. It also highlights the broad pathophysiology of SARS-CoV-2 causing neuropathy and coagulopathy; understanding this will optimise robust anticoagulation guidelines, required in VV-ECMO.
Introduction
Spine is a common site for haematological malignancies. Multiple myeloma affects the spine in 70% of cases. New guidelines were published in 2015 to help manage spinal haematological malignancies.
Despite neural compression or spinal instability, instrumentation of the spine should be avoided. Surgery carries significant risks of wound complications and more importantly delaying the definitive chemotherapy and radiotherapy. Cement augmentation and bracing for pain and prevention of deformity is key to the new strategies.
We aimed to evaluate the different treatment modalities adopted in the spine unit at St George's hospital for spinal haematological malignancies. We compared our practice to the current guidelines published in 2015.
Methods
Retrospective review of all spinal haematological malignancy patients who were discussed in the spinal MDT and managed through the spine unit at St George's hospital in the period between April 2019 and February 2021. We analysed the demographics of the patients treated in this period and compared the management modalities adopted in the unit to the current British haematological guidelines.
Introduction
Pulmonary Tuberculosis (TB) can be detected by sputum cultures. However, Extra Pulmonary Spinal Tuberculosis (EPSTB), diagnosis is challenging as it relies on retrieving a sample. It is usually discovered in the late stages of presentation due to its slow onset and vague early presentation. Difficulty in detecting Mycobacterium Tuberculosis bacteria from specimens is well documented and therefore often leads to culture negative results. Diagnostic imaging is helpful to initiate empirical therapy, but growing incidence of multidrug resistant TB adds further challenges.
Methods
A retrospective analysis of cases from the Infectious Disease (ID) database with Extra Pulmonary Tuberculosis (EPTB) between 1st of January 2015 to 31st of January. Two groups were compared 1) Culture Negative TB (CNTB) and 2) Culture Positive TB (CPTB). Audit number was
Background
Partial facetectomies with pedicle screw instrumentation is widespread and a well described technique for achieving posterior correction of scoliosis. Newton et al. first described the use of the UBS in the posterior correction of AIS in 2014. The aim of this study was to compare the effectiveness of the UBSPO in achieving posterior correction in Type1 AIS as compared to the traditional partial facetectomies. Aim of this study was to assess the effectiveness of USBPO in achieving posterior correction in Type 1 AIS as compared to partial facetectomies.
Methods
A retrospective review of 40 patients with type 1 AIS who had undergone a posterior correction of scoliosis between 2010 and 2016 was performed. Group A (n=20) consisted of consecutive patients that had partial facetectomies while Group B (n=20) consisted of consecutive patients having UBSPO. Both groups were matched for demographic parameters. Pre and post-operative radiographic parameters and operative data in both groups were compared. The Mann-Whitney U test was used for statistical analysis.
Introduction
Scoliosis surgery is a life-changing procedure, but not devoid of perioperative complications. Often patients' scoring systems do not cover their real-life needs, including return to pre-surgery activity.
Return to school, physical education (PE) is an important indirect marker of recovery. Although anterior spinal fusion (ASF) may have advantages, compared to posterior spinal fusion (PSF), because of motion-saved segments, there is a paucity of literature about post-operative return to school/PE in the compared groups.
Aim
To determine the recovery time for patients with scoliosis who underwent anterior spinal fusion (ASF) and posterior spinal fusion (PSF)
Background
The advent of EOS imaging has offered clinicians the opportunity to image the whole skeleton in the anatomical standing position with a smaller radiation dose than standard spine roentgenograms. It is known as the fifth modality of imaging. Current NICE guidelines do not recommend EOS scans over x-rays citing: “The evidence indicated insufficient patient benefit in terms of radiation dose reduction and increased throughput to justify its cost”.
Methods
We retrospectively reviewed 103 adult and 103 paediatric EOS scans of standing whole spines including shoulders and pelvis for those undergoing investigation for spinal deformity in a tertiary spinal centre in the UK. We matched this against a retrospective control group of 103 adults and 103 children who underwent traditional roentgenograms whole spine imaging at the same centre during the same timeframe. We aimed to compare the average radiation dose of AP and lateral images between the two modalities. We utilised a validated lifetime risk of cancer calculator (
Introduction
Degenerative spondylosis (DS) represents a challenging condition to diagnose and treat. There are multiple modalities to investigate DS including X-ray, MRI and CT, but symptoms may not be equivocal to DS to support the clinical findings. The investigation of metastases commonly utilises SPECT/CT for identification of areas of increased osteoblastic activity to denote disease.
The aim of the study was to analyse the prevalence of asymptomatic DS in a consecutive hospital cohort of oncology patients who had SPECT/CT for investigation of metastases.
Methods
Oncology patients who underwent SPECT/CT at St. George's Hospital were analysed between 2015–2019.
Exclusion criteria: back pain, inflammatory disorders, metastases, trauma, infection. Radiology reports were examined for DS and anatomical distribution of tracer uptake.
Introduction and Objective
Almost 60% of the population can expect to experience low back pain (LBP) during their life. Several radiological tools are used to investigate LBP. However, adequate evidence is unavailable to support the use of single photon emission computer tomography (SPECT) in patients with LBP. The objective of this study is to assess the role and efficiency of SPECT in evaluation and management of patients with LBP.
Method
Ninety-two patients with LBP were examined and assessed. All the patients received a magnetic resonance imaging (MRI) scan and were referred for a SPECT. We interpreted the modic and degenerative changes found on the MRI and compared it with SPECT tracer uptake. SPECT was used to identify the pain generator and then a surgical plan was made. Data was analyzed for pain improvement in those who underwent surgical treatment to establish the accuracy of CT SPECT in identification of primary pain generator.
Background
Carbon fibre (CF) instrumentation is known to be radiolucent and has a tensile strength similar to metal. A specific use could be primary or oligometastatic cancer where regular surveillance imaging and Stereotactic Radiotherapy are required.
CT images are inherently more prone to artefacts which affect Hounsfield unit (HU) measurements. Titanium (Ti) screws scatter more artefacts. Until now it has been difficult to quantify how advantageous the radiolucency of carbon fibre pedicle screws compared to titanium or metallic screws actually is.
Methodology
In this retrospective study, conducted on patients from 2018 to 2020 in SGH, we measured the HU to compare the artifact produced by CF versus Ti pedicle screws and rods implanted in age and sex matched group of patients with oligometastatic spinal disease.
Introduction
Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through Growth Modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemi-epiphysiodesis concept. The other modality is Anterior Scoliosis Correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected.
Methods
Retrospective analysis of clinical and radiographic data of 20 patients between 2014 to 2016 with a mean 5 year follow (range 4–6).
Introduction
Treatment of spinal metastatic disease has evolved with the advent of advanced interventional, surgical and radiation techniques. Spinal Oligometastatic disease is a low volume disease state where en bloc resection of the tumour, based on oncological principles, can achieve maximum local control (MLC). Hybrid therapy incorporating Separation surgery (>2mm clearance of the thecal sac) and Stereotactic Ablative Radiotherapy (SABR) offer an alternative approach to achieving MLC. Hybrid therapy is also a viable option in patients eligible for SBRT who have failed conventional radiation therapy. En-bloc surgery may be a suitable option for those patients who are ineligible for or have failed SBRT. A multidisciplinary approach is particularly important in the decision-making process for these patients. Metal free instrumentation is aiding the optimization of these surgeries. The authors present a supra-regional centre's experience in managing spinal oligometastases.
Methods
Retrospective review of oligometastatic spinal disease at a supra-regional centre between 2017 and 2021. Demographics, operative course, complications and Instrument type are examined.
Introduction
Missile injuries are very serious injuries particularly in the cervical region. They are classified into high and low missile injuries when it involves the cervical spine. In modern guerrilla warfare, one must be aware of ballistic pathology with bullets as well as from explosives. In particular, improvised explosive devices commonly known as IED's play a new and important pathophysiology whether they are suicided vests or roadside bombs. They usually produce severe or lethal injuries and serious neurovascular deficit is frequent. We present the details of 40 patients with local experience on how to handle serious penetrating cervical missile injuries.
Methods
All cases were collected from the record of Basrah University Hospital, Iraq. Healthy military gentlemen with ages ranging between 20–35 years were included.
INTRODUCTION
The correct placement of pedicle screws is a major part of spine fusion and it requires experienced trained spinal surgeons. In the era of European Working Time Directive (EWTD), surgical trainees have less opportunity to acquire skills. Josh Kauffman (Author of The First 20 Hours) examined the K. Anders-Ericsson study that 10,000 hours is required to be an expert. He suggests you can be good at anything in 20 hours following 5 methods. This study was done to show the use of accelerated learning in trainees to achieve competency and confidence on the insertion of pedicle screws.
METHODS
Data was collected using 3 experienced spine surgeons, 8 trainees and 1 novice (control) on the cadaveric insertion of pedicle screws over a 4 day didactic lecture in the cadaver lab. Each candidate had 2 cadavers and 156 screw placements over 4 hour shifts. Data was collected for time of pedicle screw insertion for each level on the left and right side. A pre-course and post-course questionnaire (Likert scale) was conducted.
Introduction
The placement of a large interbody implant allows for a larger surface area for fusion, vis a vis, via retroperitoneal direct anterior, antero-lateral and lateral approaches. At the same time, spinal navigation facilitates a minimally invasive fixation for inserting posterior pedicle screws. We report on the first procedures in the United Kingdom performed by a single-surgeon at a single- centre using navigated robot-assisted spine surgery without the need for guide-wires.
Materials and Methods
Whilst positioned in the supine or lateral position, a routine supine anterior lumbar interbody fusion (ALIF), and/or antero-lateral ALIF (AL-ALIF) and/or lateral lateral interbody fusion (LLIF) is performed. The patient is then turned prone or kept in the single lateral position (SPL) for insertion of the posterior screws performed under robotic guidance. Intraoperative CT scan 3D images captured then are sent to the Robotic software platform for planning of the screw trajectories and finally use again at the end of the procedure to confirm screw accuracy.
We identified 34 consecutive patients from October 2019 to January 2020 who underwent robotic assisted spine surgery. The demographic, intraoperative, and perioperative data of all these patients were reviewed and presented.
Introduction
Traditionally correction of idiopathic paediatric scoliosis is done by hybrid fixation. This involves a judicious combination of mono-axial and poly-axial screw constructs. This has inherent perceived advantages with better deformity correction and maintaining alignment without loss of correction over time.
Study design
Single centre retrospective review of prospective collected data on the radiological analysis of idiopathic paediatric scoliosis corrections. The study compared hybrid screw constructs (poly-axial & mono-axial) to all poly-axial screw constructs over 28 months.
1312 patients with idiopathic scoliosis completed the ScolioGold Body Image Questionnaire (SBIQ) before and after a course of intensive PSSE treatment. A paired T-test compared the patient's perception of Body image. Mean age was 24.7 with a range of 6 to 83 years old (<18 = 687; >18 = 625), female = 1061, male = 251).
Pre-treatment average was 5.3 (SD=2.07), which improved to 2.8 after treatment (SD=1.8). The difference of 2.6 was statistically significant (p<0.005). Pre-treatment, the patients in the children group scored 4.67, which was significantly lower than the adult group score of 6.32. On average, the children improved their scores by 2.48 to 2.19 which was statistically significant (p=0.000). The adults improved their scores by 2.81 to 3.51 which was statistically significant (p=0.000). On average patients with mild (11° to 25° Cobb angles) and moderate (26° to 50° Cobb angles) curvatures achieved a larger improvement compared to patients with severe curvatures (>50° Cobb angles). This difference of 0.35 was statistically significant (n=641, p<0.05).
There were significant improvements in the total SBIQ scores before and after treatment in both the child and adult groups with mild to severe curvatures after an intensive course of PSSE treatment. This shows that intensive PSSE treatment can improve scoliotic patients' self-image, therefore addressing aspects of their psychosocial well-being.
Adolescent Idiopathic Scoliosis (AIS) patients were subjected to four weeks of Physiotherapy Scoliosis Specific Exercise (PSSE). 124 (Exclusion = 3) Patients were enrolled and assigned to either complete their treatment in one 4-week bout (4WC) (63 patients,
Group 1 (4WC) showed significant improvements from baseline (Pre-3.73 – Post 3.9; p=0.026) after the course of treatment, and showed significant improvements at 12 months follow up in Mental Health (p=0.006), Aggregate score (p= 0.005) and Satisfaction score (p=0.011). Satisfaction score remained statistically significant at 18 months follow up (p=0.016). Group 2 (2X2WC) did not record a significant improvement from baseline (p=0.058); however, showed significant improvements in self-image (p=0.013). There was no statically significant difference in SRS scores with respect to follow up time.
We conclude that Physiotherapy Scoliosis Specific Exercise (PSSE) is a successful non-invasive therapy for AIS. The modified Schroth technique (ScolioGold) shows significant improvement in SRS30 scores with the 4-week intensive course that are sustained at a 2 year follow up.
Endoscopic spine surgery is a promising and minimally invasive technique for the treatment of disc herniation and spinal stenosis. However, the literature on the outcome of interlaminar endoscopic decompression (IED) versus conventional microsurgical technique (CMT) in patients with lumbar spinal stenosis is scarce. We analyzed 88 patients (IED: 36/88, 40.9%; CMT: 52/88, 59.1%) presenting with lumbar central spinal stenosis between 2018–2020. Surgery-related (operation time, complications, time to hospital release (THR), ASA score, C-reactive protein (CRP), white blood cell count (WBC), side (unilateral/bilateral), patient-reported (ODI, NRS (leg-, back pain), eQ5D, COMI), and radiological (preoperative dural sack cross-sectional area (DSCA), Shizas score (SC), left (LRH) and right (RRH) lateral recess heights, left (LFA) and right (RFA) facet angle) parameters were extracted.
Complication (most often re-stenosis due to hematoma and/or residual sensorimotor deficits) rates were higher in the endoscopic (38.9%) than microsurgical (13.5%) treatment group (p<0.01). Age, THR, SC, CRP, and DSCA revealed significant correlations with 3 weeks and 1 year postoperatively evaluated ODI, COMI, eQ5D, NRS leg, or NRS back values in our cohort. We did not observe significant differences in the endoscopic versus microsurgical group for the patient-reported outcomes.
Age, THR, SC, CRP, and DSCA revealed significant correlations with patient-centered outcomes and should be considered in future studies. Endoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach, although it was associated with higher complication rates in our single-center study experience. This was probably because of the surgeons' lack of experience with this method and the resulting different learning curve compared with the conventional technique.
Introduction
Patients with metastatic spinal cord compression (MSCC) or unstable spinal lesions warrant early surgical consultation. In multiple myeloma, chemotherapy and radiotherapy have the potential to decompress the spinal canal effectively in the presence of epidural lesions. Mechanical stability conferred by bracing may potentiate intraosseous and extraosseous bone formation, thus increasing spinal stability. This study aims to review the role of non-operative management in myeloma patients with a high degree of spinal instability, in a specialist tertiary centre.
Methods
Retrospective analysis of a prospectively collected database of 83 patients with unstable myelomatous lesions of the spine, defined by a Spinal Instability Neoplastic Score (SINS) of 13–18. Data collected include patient demographics, systemic treatment, neurological status, radiological presence of cord compression, most unstable vertebral level and presence of intraosseous and extraosseous bone formation. Post-treatment scores were calculated based on follow-up imaging which was carried out at 2 weeks for cord compression and 12 weeks for spinal instability. A paired t-test was used to identify any significant difference between pre- and post-treatment SINS and linear regression was used to assess the association between variables and the change in SINS.
SUMMARY
A retrospective cohort study of 19 patients of EOS who underwent MCGR rod instrumentation with subsequent serial distractions, measured using ultrasonography. The degree of distraction achieved during each session were analyzed and subgroup analysis done.
HYPOTHESIS
The degree of distraction/ distractibility of the MCGR rod is closely linked to the etiology of EOS. The degree of distraction achieved at each session progressively diminishes with successive distractions.
Lumbar fusion remains the gold standard for the treatment of discogenic back pain. Total disc replacement has fallen out of favor in many institutions. Other motion preservation alternatives, such as nucleus replacement, have had limited success and none are commercially available at this time.
Two prospective, nonrandomized multicenter studies of lumbar disc nucleus replacement using the PerQdisc 2.0 nucleus replacement device in patients with lumbar discogenic back pain. Early clinical results are presented. A total of 16 patients from 4 international sites (Germany, Paraguay, Canada and Belgium) were enrolled in the trial between May 2019 and February 2021. Data collection points include baseline and postoperatively at 1, 2, 6, and 12 months. Clinical outcome measures were obtained from the Visual Analog Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), SF-12V2, Analgesic Score (AS), and radiographic assessments. Prospectively gathered data on patient reported outcomes, neurological outcome, surgical results, radiological analysis, and any adverse events.
16 patients had successful implantation of the device. There have been no expulsions of the device. Early postoperative results are available in 13/16 patients at 6 months and 11/16 patients at 12 months. There have been 4 (25%) revision surgeries 3–12 months post implantation between the two trials. 12 of 13 (92%) patients had Minimal Clinically Important Difference (MCID) in ODI at 6 months and 10 of 11 (91%) at 12 months. Mean decrease in ODI from baseline to 12 months was 44.8. At 12 months 8 (73%) patients are not taking pain medication, 1 (9%) patient is taking a narcotic for pain management. 73% of patients are working without restrictions at 12 months post implant.
Early clinical and technical results are encouraging. Long term follow up is essential and is forthcoming. Additional patient recruitment and data points are ongoing.
Microdiscectomy is the most commonly performed spine surgery in the world. Due to its technical simplicity and low complication rate, this was the first spine surgical procedure transitioning for one-day surgery. However, the economic assessment of this outpatient transition was never performed and the question on the real impact in the burden of spine care remains.
This economic study aims to access the cost-utility of outpatient lumbar microdiscectomy when compared with the inpatient procedure.
To do so, a cost-utility study was performed, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy, from a in a Portuguese NHS hospital. Utilities were calculated with quality-adjusted life-years were derived from Oswestry Disability Index values (ODI). ODI was assessed prospectively in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. both probabilistic and deterministic sensitivity analyses were performed and incremental cost-effectiveness ratio (ICER) calculated. A willingness to pay (WTP) threshold of €60000/QALY gained with inpatient procedure was defined.
Out results showed that inpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135753 to €345755/QALY, higher than the predefined WTP. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group. The mean admission time in inpatient group was 2.5 days. Since there is an overall agreement among spine surgeons that an uncomplicated inpatient MD would only need a one-day admission, an analysis reducing inpatient admission time for one day was also performed and outpatient remained cost-effective.
In conclusion, as the first economic study on cost-utility of outpatient lumbar microdiscectomy, this study showed a significant reduction in costs, with a similar clinical outcome, proving this outpatient transition as cost-effective
Although interlaminar endoscopic lumbar discectomy (IELD) is considered to be less invasive than microscopic lumbar discectomy (MLD) in treatment of lumbar herniated nucleus pulposus, the radiologic change of multifidus muscles by each surgery has rarely been reported. The aim of the present study was to compare the quantitative and qualitative changes of multifidus muscles between two surgical approaches and to analyze the correlation between various parameters of multifidus muscles and long term surgical outcome.
21 patients who received MLD and 18 patients who received IELD in a single tertiary hospital were enrolled and their preoperative, postoperative (≤15 days), and follow-up (≥6 months) MRIs were analyzed. The cross-sectional area (CSA) and fatty degeneration rate (FD) were quantitatively estimated at the level of surgery. The correlations among CSA, FD, body mass index, follow-up visual analogue scale(VAS) and Oswestry Disability Index(ODI) were assessed.
Mean intervals of postoperative MRI and follow-up MRI from surgery were 3.0±3.7 days and 14.5±10.7 months, respectively. During the follow-up period, VAS was improved from 7.1±1.3 to 2.1±1.8 in MLD and from 8.2±1.4 to 2.2±1.8 in IELD. In cases of MLD, comparing with preoperative MRI, ipsilateral CSA was significantly increased in postoperative MRI (795.6mm2 vs. 906.5mm2, p<0.01), but it was not significantly different in follow-up MRI (795.6mm2 vs. 814.4mm2, p=1.00). However, in case of IELD, the ipsilateral CSAs in preoperative, postoperative, and follow-up periods were 892.0 mm2, 909.3 mm2, and 900.3 mm2, respectively. These changes were not significant over time (p=0.691). The ipsilateral FDs were not significantly changed between preoperative and follow-up periods in both MLD (21.4% vs. 20.9%, p=0.81) and IELD groups (23.5% vs. 21.8%, p=0.19). The increment of ipsilateral CSA had significant correlations with follow-up ODI (r=−0.368, p=0.02).
Comparing with IELD, MLD induced more surgical trauma on multifidus muscle in postoperative period, but the muscular damage was recovered in follow-up period. IELD can minimize surgical trauma on multifidus muscle showing similar pain relief as MLD. Favorable surgical outcome in follow-up period may be related to increment of multifidus muscle volume.
Figure 1
(A-C) The multifidus muscles in preoperative, postoperative, and follow-up periods, respectively, in patient with MLD. Comparing with preoperative period, the CSA of right multifidus muscle (ipsilateral side) was increased in postoperative period, but recovered in follow-up period. (D-F) The multifidus muscle in preoperative, postoperative, and follow-up periods, respectively, in patient with IELD. The CSA of left multifidus muscles (ipsilateral side) was not significantly changed over time. Comparing preoperative MRIs with follow-up MRIs, the FDs of multifidus muscles were not significantly changed regardless of surgical technique.
Figure 2
The CSA was measured by marking region of interest (ROI) and FD was measured by calculating the rate of pixels beyond the threshold in ROI. All measurements were performed using ImageJ software (version 1.52a, National Institutes of Health, Bethesda, Maryland, USA).
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